Payment of health care insurance claims using short-term loans

ABSTRACT

Methods and systems for promptly paying health care providers for rendered health care services. A medical technician operating a client computer establishes communication with a remote server. Using a claim form, the technician enters patient, insurance, and treatment information which is transmitted to the server to determine whether the claim is eligible for advance payment. If the claim is eligible, the server transmits claim information to an appropriate carrier for claim processing. The remote server also transmits claim information to a payment entity which requests from a financial entity that funds be credited to an operational account and a reserve account. The funds of the operational account are immediately accessible to the health care provider. The funds of the reserve account are debited for expenses. When the carrier finally processes the claim, any payment for the claim is deposited into the reserve account.

RELATED APPLICATION

This application is a divisional of U.S. patent application Ser. No.09/756,077, filed Jan. 8, 2001, now U.S. Pat. No. 7,072,842 which isincorporated herein by reference.

BACKGROUND OF THE INVENTION

1. The Field of the Invention

The present invention relates to systems and methods for approving andpaying health care insurance claims promptly. More particularly, thepresent invention relates to systems and methods for promptly payinghealth care providers for services rendered before the health careinsurance claims can be processed and, if necessary, adjudicated by anassociated carrier or payer.

2. Relevant Technology

The cost of health care continues to increase as the health careindustry becomes more complex, specialized, and sophisticated. Theproportion of the gross domestic product that is accounted for by healthcare is expected to gradually increase over the coming years as thepopulation ages and new medical procedures become available. Over theyears, the delivery of health care services has shifted from individualphysicians to large managed health maintenance organizations. This shiftreflects the growing number of medical, dental, and pharmaceuticalspecialists in a complex variety of health care options and programs.This complexity and specialization has created large administrativesystems that coordinate the delivery of health care between health careproviders, administrators, patients, payers, and carriers. Althoughbeneficial in some respects, the administrative system has increased theoverall cost of health care while, at the same time, making it difficultfor health care providers to receive advance payment for servicesrendered.

There are several reasons to account for the detrimental effect thatlarge administrative systems have had on the advance payment of claimsfor health care services. For example, a single health managementorganization may review tens of thousands of payment requests each dayand tens of millions of requests a year. The sheer volume of paymentrequests alone creates a backlog of unpaid claims. Additionally, thecontractual obligations between parties are complex and may changefrequently. Often, there are many different contractual arrangementsbetween patients, payers or carriers, and health care providers. Theamount that is authorized for payment may vary by the service orprocedure, by the particular contractual arrangement with each healthcare provider, by the contractual arrangements between the carrier orpayer and the patient regarding the allocation of payment for treatment,and by what is considered consistent with current medical practice. As aresult of any changes in these contractual relationships, it is oftennecessary to spend additional time reviewing and analyzing claims,further delaying the payment for services rendered. This is particularlytrue when claims are submitted with clerical errors, in which case theclaim will be disputed and may ultimately have to be resubmitted.

When a claim is disputed, it must be adjudicated to determine exactlywhich services are authorized and how much a health care provider willbe paid. Adjudicating a claim can take several weeks or months and mayrequire multiple submissions of the same claim. While a claim is beingadjudicated, a health care provider is left without funds for servicesthat have already been rendered, and as a result, the health careprovider may suffer serious financial problems that are associated withcash flow realities.

During recent years, there has been an attempt to expedite the paymentof health care services by automating the process for creating,reviewing, and adjudicating payment requests. For example, therecurrently exist claims processing systems whereby technicians at healthcare providers' offices electronically create and submit medicalinsurance claims to a central processing system. The technicians inputinformation identifying the physician, patient, medical service, carrieror payer, and other data with the medical insurance claim. The centralprocessing system verifies that the physician, patient, and carrier orpayer are participants in the claims processing systems. If so, thecentral processing system converts the medical insurance claim into theappropriate format of the specified carrier or payer, and the claim isthen forwarded to the carrier or payer. Upon adjudication and approvalof the insurance claims, the carrier or payer initiates a check to theprovider. In effect, such systems bypass the use of the mail fordelivery of insurance claims and save overall time.

However, even using these automated systems, medical technicians at thehealth care provider's office are often unable to determine whether theclaim, as it is submitted, is in condition for payment. If the claim isnot in condition for payment then the claim will undergo a protractedadjudication, which may include multiple resubmissions of the sameclaim. For example, it has been found that a large number of insuranceclaims are submitted with information that is incomplete, incorrect, orthat describes diagnoses and treatments that are not eligible forpayment. Accordingly, these claims may be rejected for any of a largenumber of informalities, including clerical errors, patientineligibility, indicia of fraud, etc. The health care provider, however,is not made aware of the deficiencies of the submitted claims until alater date, potentially weeks afterwards, when the disposition of theinsurance claim is communicated to the health care provider. As aresult, many claims are subject to multiple submission and adjudicationcycles, as they are successively created, rejected, and amended. Eachcycle may take several weeks or more. The resulting duplication ofeffort decreases the efficiency of the health care system and increasesthe time it takes to process a claim.

Studies have shown that some insurance claim submission systems rejectup to 70% of claims on their first submission for including inaccurateor incorrect information or for other reasons. Many of the claims areeventually paid, but only after they have been revised in response to aninitial rejection. Thus, while systems that permit electronic submissionof insurance claims marginally decrease the time needed to receivepayment by eliminating one or more days otherwise required to deliverclaims by mail, they remain subject to many of the problems associatedwith conventional claims submission systems. Accordingly, even automatedsystems that are designed to improve the efficiency of the healthmanagement systems have ultimately failed to provide an adequate meansfor promptly paying health care providers for services rendered.

Some health care providers cannot afford the luxury of waiting anextended period of time for claims to be processed because of financialobligations related to operating expenses and overhead. This isparticularly true for health care providers who purchase new equipmentand hire experienced staff. Any delay in receiving payment can createcash flow problems. Accordingly, in order to attempt to minimize thenumber of claims that are rejected and effectively reduce the overallamount of time it will take to get paid, physicians or their staff havehad to spend inordinate amounts of time investigating which treatmentswill be covered by various insurance carriers and insurance plans.Normally, such activity involves calling insurance carriers over thetelephone. The time spent in such activities, however, increasesoverhead costs and represents further efficiency losses in the healthcare system. One consequence of the inefficient and lengthy claimsprocessing system is that some health care providers are deterred frompurchasing new equipment and hiring experienced, high-salary, staffbecause of cash flow constraints.

One way to improve cash flow is to require payment for services at thetime of service. This, however, may be prohibitive, depending upon thecost of the health care services provided and the ability of a patientto pay. Moreover, many patients are not willing to pay for health careservices at the time they are rendered because they are either coveredby insurance or they believe they are covered by insurance. Depending ona patient's insurance plan and the diagnosis and treatment rendered,however, the patient may be required to make a co-payment representing,for example, a certain percentage of the medical bill or a fixed dollaramount. Because of the large number of insurance carriers and insuranceplans, however, the amount of the co-payment can vary from patient topatient and from visit to visit. In fact, some insurance plans do notrequire the patient to make a co-payment at all, in which case thehealth care provider must wait for the insurance claim to be processedand adjudicated. Accordingly, the various insurance plans make itdifficult to know exactly how much co-payment each patient is requiredto make. This is particularly true when coverage of an insurance plan isbased on percentages of total services and not on flat co-paymentamounts. The uncertainty regarding co-payments makes it even moredifficult for health care providers to receive advance payment forservices rendered, particularly for the patient's portion of costspertaining to the health care services. Furthermore, once the patientleaves the office, the expense of collecting amounts owed by the patientincreases and the likelihood of getting paid decreases.

In view of the foregoing, there is a need in the art for providinghealth care providers with advance payment for services rendered. Forexample, it would be an advancement in the art to provide a claimspayment system that would enable health care providers to receivepayment for services rendered prior to the completion of a conventionalclaims adjudication process, particularly when the adjudication processis protracted due to claim informalities and administrativeinefficiencies. It would also be an advancement in the art to provide aclaims payment system that would enable health care providers to knowexactly how much co-payment to request from a patient prior todischarging the patient.

SUMMARY OF THE INVENTION

The present invention relates to methods and systems for promptlyapproving and paying health care providers for services rendered.According to the present invention, a medical technician can prepare aninsurance claim electronically, submit the claim via the Internet oranother wide area network, and receive almost immediately an indicationwhether the patient is covered by insurance and whether the submittedclaim is in condition for advance payment. If the claim is not incondition for advance payment, the health care provider is notified ofthe claim rejection and can properly amend the claim by correcting theerrors. Once it is determined that the claim is in condition for advancepayment, the claim is submitted to the patient's carrier or payer forconventional claims processing and, if necessary, adjudication. Theclaim is simultaneously submitted to a payment entity where it isdetermined what funds should be advanced to the health care provider andhow the funds are to be distributed.

The present invention can significantly reduce the amount of time ittakes for a health care provider to receive payment for servicesrendered. This is particularly true when a claim is ultimately subjectedto a lengthy adjudication process in the conventional claims processingby a patient's carrier or payer. The invention can also significantlyreduce the time, effort, and expense that have been associated with thesubmission of claims that are not in condition to be paid, such asclaims that are submitted with clerical errors. A medical technician canalso receive an almost immediate indication of any co-payment that isrequired of a patient. This further enhances the likelihood and abilityof a health care provider to receive advance payment for servicesrendered.

According to the present invention, communication is established betweena client computer, operated by a health care provider, and a remoteserver computer. The communication can be established using theInternet, a direct-dial telephone line, or any other suitable wide areanetwork infrastructure. The client computer displays acomputer-displayable claim form to the health care provider which isused to create an insurance claim. The claim, including patientidentification, insurance information, and treatment information istransmitted electronically from the client computer to the servercomputer. Although the present invention is most efficient whenelectronic claim forms are used, paper claim forms and conventional mailsystems can also be used to submit claims to the remote server. Thepresent invention is an improvement over the prior art, even whenconventional mail systems are used, because it reduces the total time ittakes for health care providers to receive payment for servicesrendered. In particular, the present invention provides systems andmethods for promptly paying health care providers for services rendered,even before the claims are processed by the health insurance carrier. Ifpaper claim forms are submitted by a participating health care provider,the claims are subsequently converted into an electronic format viaOCI/OCR imaging or manual entry.

Upon receiving a claim, the remote server determines whether the claimin condition for advance payment using various auto automated processes.If necessary, the medical technician using the client computer canrevise the claim to cause it to be in condition to be paid. When theremote server finally determines that the claim is in condition foradvance payment, the remote server submits the claim to the patient'shealth insurance carrier for conventional claims processing and, ifnecessary, adjudication. The claim is sent electronically if the carrieris equipped to receive electronic claims. Otherwise, claims are sent byconventional mail in paper format. The claims processing andadjudication of a carrier may take several weeks or months. To expeditethe payment of claims to health care providers, the present inventionprovides a method and a system for providing health care providers withadvanced payment for services rendered, even before insurance claims forthose services can be processed and adjudicated by a correspondingcarrier or payer. To do this, the remote server also submits claims to apayment entity where it is determined what funds should be advanced tothe health care provider and how the funds are to be distributed.

The remote server then transmits information to the client computer tonotify the health care provider of the various determinations that havebeen made. The information transmitted to the client computer caninclude data that represents an amount that is to be paid by the carrieror payer on behalf of the patient and any co-payment to be collectedfrom the patient. The information can also indicate how much money willbe advanced to the provider to promptly pay for rendered services.Typically, this amount corresponds with the amount that is to be paid bythe carrier or payer. Because these processes, as described above, canoccur almost instantaneously, typically in a matter of seconds orminutes, any co-payment can be collected from the patient before thepatient is discharged from the offices of the health care provider. Theremaining funds can then be received either by the carrier or payerthrough normal operations or they can be made almost immediatelyavailable using a short-term loan.

Upon receiving claim data, the payment entity cooperates with afinancial entity to advance a credit of funds into two separateaccounts, an operations account and a reserve account. Explanation ofpayments (EOP) data can be made available for the health care providerto view over the Internet as soon as the payment entity authorizes funddistribution. The EOP data explains the distribution of funds to each ofthe accounts and can be updated by the payment entity and/or by thefinancial entity.

In one example, the operations account is credited with approximately80% of the advance and is immediately accessible by the health careprovider to meet financial obligations and to avoid cash flow problems.The reserve account is credited with approximately 20% of the advance.The funds of the reserve account are not immediately accessible to thehealth care provider. The reserve account is debited to cover processingfees, interest on the outstanding balance of the credit advance, and topay down the outstanding balance of the credit advance, if any.

When the carrier or payer finally completes the processing andadjudication of the claim, the payment for services rendered issubmitted to the provider's reserve account to pay down the outstandingbalance and the interest on the outstanding balance. The payment to thereserve account can be made electronically with an electronic fundtransfer or by check. The carrier or payer submits an explanation ofbenefits (EOB) form to the patient when the processing of the claim iscomplete. EOB data can also be made accessible online.

In view of the foregoing, the invention provides systems and methods forenabling health care providers to be promptly paid for servicesrendered. A claim can be submitted, verified and approved for advancepayment almost instantaneously. A claim that is not in condition foradvance payment can be immediately amended for approval. A health careprovider is notified of the amount that is authorized for advancepayment and of any co-payments that are due from the patient so thatthey can be collected before the patient is discharged. The approvedamount of advance payment is distributed between into two accounts, oneof which provides the health care provider with immediate access tofunds for health care services rendered, even before the carrier orpayer has paid for the services.

Additional features and advantages of the invention will be set forth inthe description which follows, and in part will be obvious from thedescription, or may be learned by the practice of the invention. Thefeatures and advantages of the invention may be realized and obtained bymeans of the instruments and combinations particularly pointed out inthe appended claims. These and other features of the present inventionwill become more fully apparent from the following description andappended claims, or may be learned by the practice of the invention asset forth hereinafter.

BRIEF DESCRIPTION OF THE DRAWINGS

In order to describe the manner in which the above-recited and otheradvantages and features of the invention can be obtained, a moreparticular description of the invention briefly described above will berendered by reference to specific embodiments thereof which areillustrated in the appended drawings. Understanding that these drawingsdepict only typical embodiments of the invention and are not thereforeto be considered to be limiting of its scope, the invention will bedescribed and explained with additional specificity and detail throughthe use of the accompanying drawings in which:

FIG. 1 is schematic diagram illustrating an interactive system accordingto the invention, including a client system located at the offices of ahealth care provider, a remote server system, a carrier or payer, apayment entity, and a financial institution that includes a reserveaccount and an operational account.

FIG. 2 illustrates an insurance claim form that enables a medicaltechnician to determine whether and to what extent a patient is abeneficiary of an approved insurance plan.

FIG. 3 illustrates an insurance claim form that enables a medicaltechnician to submit an insurance claim including one or more diagnosiscodes and one or more treatment codes.

FIG. 4 is a flow diagram illustrating one embodiment of the methods ofthe invention for paying a claim after determining that the claim is inallowable condition for advance payment.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention relates to systems and methods for promptly payinghealth care providers for services rendered, even before paymentrequests for the rendered services can be processed and adjudicated bycorresponding carrier or payers.

A medical technician at the offices of a health care provider operates aclient computer that communicates with a remote server. According to oneembodiment of the invention, the medical technician views acomputer-displayable claim form displayed by the client computer andenters patient information, insurance plan information, and treatmentinformation which includes a diagnosis code and a treatment code thatdescribe a medical diagnosis and associated treatment performed on apatient by the health care provider. The patient information, insuranceplan information and treatment information are transmitted to the remoteserver. Upon receiving this information, the remote server performs anoperation to determine whether the patient is approved by the carrier orpayer of the insurance plan or of another insurance plan. The remoteserver may also perform an operation to the treatment information todetermine whether the diagnosis code and the treatment code correspondto health care services that are approved for advance payment.

If the remote server determines that the patient is not covered by anapproved insurance plan or that the submitted claim is not in allowablecondition for advance payment, the remote server transmits informationto the client computer to inform the medical technician of this result.In response, the medical technician can amend the patient information,insurance plan information or treatment information to place the claimin allowable condition for advance payment. After amending the claim,the claim is again submitted to the remote server, where it is againanalyzed to determine whether the patient is covered by an approvedinsurance plan and whether the claim is in allowable condition foradvance payment. The remote system can also inform the health careprovider of any co-payment to be collected from the patient before thepatient is discharged so that the co-payment can be receivedimmediately.

According to one presently preferred embodiment, when the remote serverdetermines that a submitted claim is in condition for advance payment,the remote server transmits the claim data to the carrier or payer forprocessing while simultaneously submitting the claim data to a paymententity which determines exactly how much money will be advanced for theservices performed and how the funds are to be distributed. Once thisdetermination is made, the client computer can access data over theInternet that provides an explanation of payment (EOP) regarding howmuch money is to be advanced and how the money is to be distributed.

In one embodiment, the approved distribution funds are distributedbetween two accounts of a financial entity, such as a bank. The twoaccounts include a reserve account and an operational account. The fundsof the operational account comprise a significant percentage of theadvanced funds and are immediately accessible to the health careprovider. These funds are made available to the health care providerwithin hours or days, well before the corresponding insurance claim canbe processed and adjudicated by the carrier or payer, which can takeweeks or months. The reserve account is credited with the balance of theadvanced funds. The funds of the reserve account are not accessible tothe health care provider, but are instead debited for service fees,interest for outstanding balances, and to pay off any outstandingbalances. When the insurance claim is finally processed by the carrieror payer, the claim payment is credited to the reserve account and theEOP data is updated. After expenses have been paid by the reserveaccount, the remaining balance is transferred to the operationalaccount, thereby making the remaining funds available to the health careprovider.

Embodiments of the invention include or are incorporated incomputer-readable media having computer-executable instructions or datastructures stored thereon. Examples of computer-readable media includeRAM, ROM, EEPROM, CD-ROM or other optical disk storage, magnetic diskstorage or other magnetic storage devices, or any other medium capableof storing instructions or data structures and capable of being accessedby a general purpose or special purpose computer. Computer-readablemedia also encompasses combinations of the foregoing structures.Computer-executable instructions comprise, for example, instructions anddata that cause a general purpose computer, special purpose computer, orspecial purpose processing device to execute a certain function or groupof functions. The computer-executable instructions and associated datastructures represent an example of program code means for executing thesteps of the invention disclosed herein.

The invention further extends to computer systems for interactivelypreparing and paying insurance claims and determining whether the claimsare in condition to be paid. Those skilled in the art will understandthat the invention may be practiced in computing environments with manytypes of computer system configurations, including personal computers,multi-processor systems, network PCs, minicomputers, mainframecomputers, and the like. The invention will be described herein inreference to a distributed computing environment, such as the Internet,where tasks are performed by remote processing devices that are linkedthrough a communications network. In the distributed computingenvironment, computer-executable instructions and program modules forperforming the features of the invention may be located in both localand remote memory storage devices.

1. Network Environment

FIG. 1 illustrates an embodiment of the systems and methods forpreparing and promptly paying health insurance claims according to thepresent invention. Client system 10 may be located at the offices of ahealth care provider in order to allow a medical technician to createand submit insurance claims. As used herein, the term “health careprovider” is to be broadly construed to include any physician, dentist,medical practitioner, or any other person whose services can becompensated by a health insurance carrier or payer, a health maintenanceorganization, or the like. As used herein, the term “medical technician”represents any person who engages in the activity of preparing orsubmitting insurance claims on behalf of a health care provider. Sincemedical technicians are typically employees of health care providers,representatives of health care providers, or may be the health careproviders themselves, any of the claims that recite acts, operations, orprocesses conducted by “health care providers” are to be construed toextend to the same acts, operations, or processes conducted by “medicaltechnicians”, as well. The terms “carrier” and “payer” are generallyinterchangeable, and any reference to “carrier” in the specification orclaims extends to entities that can be classified as “payers” unlessotherwise specified.

The term “insurance plan” extends to any contractual or other legalarrangement whereby medical and other related expenses are paid by acarrier on behalf of a patient beneficiary. Examples of insurance plansinclude health maintenance organizations, fee-for-service health careplans, employer-sponsored insurance plans, etc.

Client system 10 can be a general purpose computer, such as a personalcomputer, or a special purpose computer adapted to perform the functionsand operations disclosed herein. Client system 10 may include a displaydevice such as a monitor for displaying claim form 12, as will bedisclosed in greater detail below, and one or more input devices such asa keyboard, a mouse, etc. for enabling a medical technician to enter therequired information to client system 10.

The embodiment illustrated in FIG. 1 also includes a server system 14located typically at a remote location with respect to client system 10.Server system 14 can include a general purpose computer or a specialpurpose computer adapted to execute functions and operations of theinvention. For example, in FIG. 1, server system 14 includes a processor16, which represents a general purpose computing device for receivinginformation associated with insurance claims and for determining whetherthe received insurance claim is in allowable condition for advancepayment. The operation of server system 14 and processor 16 will bediscussed in greater detail below.

In one embodiment, processor 16 is capable of accessing informationstored in a patient eligibility database 18 and an accepted medicalpractice database 20. Database 18 can include compilation of data thatenables server system 14 to determine whether a particular patientidentified at client system 10 is a beneficiary of an approved insurancehealth plan. Likewise, database 20 can be any compilation of data thatenables service system 14 to determine whether the health care servicesassociated with a submitted claim are approved for advance payment.Generally, a submitted claim is approved for advance payment if it isdetermined that the patient is a beneficiary of an approved insurancecarrier/plan and the services rendered are qualified services under theparticular insurance plan of the patient.

While the illustrated components of server system 14 of FIG. 1 can belocated at a single remote site with respect to client system 10, otherembodiments of the invention employ a processor 16 and databases 18 and20 that may be located at different sites with respect to each other.The terms “server system” and “remote server” extend to the latter case,wherein the various components 16, 18, and 20 are located in adistributed environment unless specifically indicated otherwise.

In the embodiment of FIG. 1, client system 10 and server system 14communicate by means of Internet infrastructure 22. While the inventionis described herein in the context of the Internet, those skilled in theart will appreciate that other communications systems can be used, suchas direct dial communication over public or private telephone lines, adedicated wide area network, or the like. It should also be appreciatedthat the present invention, although preferably practiced over anInternet infrastructure, can also be practiced using conventional papermailing systems and paper claim formats. However, before the serversystem can determine whether a claim is in allowable condition foradvance payment, the claim must first be converted into an electronicformat. This can be accomplished by using any suitable optical characterrecognition (OCR) or optical character imaging (OCI) software andhardware, or by manual data entry.

2. Claim Preparation and Adjudication

The following discussion relates to processes of creating andadjudicating insurance claims using a computer network. Although thefollowing techniques can facilitate the insurance claim creation andadjudication process, the methods of paying insurance claims accordingto the invention, including advancing funds to the health care providerusing a short-term loan, can be practiced in connection with insurancesclaim prepared and adjudicated in other ways, such as other electronicor paper insurance claims. Further details relating to the followinginsurance creation and adjudication processes are disclosed in U.S. Pat.No. 6,343,271, issued Jan. 29, 2002 and U.S. Pat. No. 6,341,265, issuedJan. 22, 2002, both of which are incorporated herein by reference.

Referring to FIG. 1, when a medical technician desires to prepare aninsurance claim for health care services, the medical technicianoperates client system 10 and establishes communication with serversystem 14 or verifies that communication has been established. Forinstance, the medical technician may use client system 10 to dial into amodem pool associated with an Internet service provider in Internetinfrastructure 22. After communication with the Internet serviceprovider has been achieved, client system 10 may be used to transmit aUniform Resource Locator (URL) to the Internet infrastructure 22 thatrequests access to resources provided by server system 14.Alternatively, any other suitable technique can be used to establishcommunication between client system 10 and server system 14.

In many cases, client system 10 can maintain communication with serversystem 14 for an extended period of time during which claims formultiple patients are processed. For instance, client system 10 can be adedicated terminal that maintains communication with server system 14 inorder for numerous insurance claims to be created and processed.

Once communication has been established, the medical technician can useclient system 10 to request claim form 12 to be displayed on a monitorassociated with client system 10. Claim form 12, in one embodiment, is aHyper Text Markup Language (HTML) document retrieved from server system14 and displayed to the medical technician. Alternatively, claim form 12can have any other suitable format or can be stored at a local cache orany other local data storage system, thereby eliminating the need torepeatedly retrieve claim form 12 from a remote location as multipleinsurance claims are created.

FIG. 2 illustrates one example of a claim form 12A that enables amedical technician to verify that a patient is a beneficiary of aninsurance plan and to learn of the details of the insurance plan. Inthis embodiment, claim form 12A includes a field 26 to which a patientidentifier can be entered. Patient identification information, such aspatient information 28 of FIG. 1, is entered by the medical technicianinto claim form 12A of FIG. 2. Depending on the manner in which theinvention is implemented, the medical technician may be required toenter other information, such as insurance information 30 of thepatient, or other information 32 of FIG. 1. Other information 32 mayinclude health care provider identification, or the like. Returning toFIG. 2, claim form 12A includes a field 34 for identifying the insuranceplan of the patient, a field 36 for receiving information identifyingthe health care provider and a field 38 for entering additionalinformation identifying the patient. As shown in FIG. 2, field 38 can beadapted to receive a patient's date of birth. Alternatively, any otherinformation that can uniquely identify a particular patient from among apool of patients can be used in combination with fields 26 and 38. Byway of example and not limitation, the patient identificationinformation entered to fields 26 or 38 can be modified to includepatient's social security number, or any other number uniquelyassociated with the patient by a carrier or a health maintenanceorganization.

Referring now to FIG. 1, after the medical technician has enteredpatient identifier 28, insurance information 30, and, optionally, otherinformation 32, the medical technician uses client system 10 to transmitthe information to server system 14. In one embodiment, processor 16compares patient identifier 28 against data stored in patienteligibility database 18 to determine if the patient is a beneficiary ofan insurance health plan and, if so, the details of the benefitsthereof. If the patient is found not to be a beneficiary of an approvedinsurance health plan, information is transmitted from server system 14to client system 10 to inform the medical technician of this result.Thus, when the patient is not a beneficiary, a medical technician andthe health care provider can promptly learn of this status and takeappropriate steps to modify the claim to correct errors, if any, thatprevented the patient from being recognized as a beneficiary of anapproved health insurance plan.

If it is determined that the patient is a beneficiary, information islikewise transmitted from server system 14 to client system 10 informingthe medical technician of the patient's status. This information canalso provide details of the coverage provided to the patient that canallow the health care provider to know how much of a co-pay to requestfrom the patient before the patient is discharged from the office.Information can also contain details regarding the types of diagnosesand treatments that are approved for payment, as well as correspondingdiagnosis and treatment codes, so that the medical technician does nothave to spend inordinate amounts of time researching to know what codescorrespond to the services performed.

The medical technician can complete the claim form by entering treatmentinformation 40 that includes at least one diagnosis code 42 and onetreatment code 44. Referring now to FIG. 3, claim form 12B includesfields specifically adapted to accept the diagnosis code 42 and thetreatment code 44. Claim form 12B of FIG. 3 and claims form 12A may beseparate forms displayed to the medical technician using client system10 or can be separate portions of the single claim form. Claim form 12B,in the example of FIG. 3, includes header information 50 that has beenautomatically prepared by the server system before claim form 12B wastransmitted to the client system. Providing a claim form 12B that isautomatically partially completed contributes to the efficiency of theclaims creation and submission processes of the invention. While claimform 12B represents a claim form that can be advantageously used by manyhealth care providers, the specific fields included in the form and theinformation displayed on the form may vary from one implementation toanother, depending on the type of health care provider, insurance plan,and other factors.

Claim form 12B includes a plurality of fields 52 designed to receive anddisplay diagnosis codes representing the health care provider'sdiagnosis of the patient or the nature of the patient's illness orinjury. Thus, as used herein, “diagnosis code” refers to any informationthat specifies or indicates a patient's condition as diagnosed by ahealth care provider. Any predefined set of diagnosis codes can be usedwith the invention.

Claim form 12B also includes one or more fields 54 designed to receiveand display treatment codes associated with the diagnosis code of field52. As used herein, “treatment codes” can represent any type of healthcare services, including, but not limited to clinical therapy,pharmacological therapy, therapeutic supplies or devices, and othergoods or services that can be paid for by health insurance plans orhealth maintenance organizations. The treatment codes can be selectedfrom any desired set of predefined treatment codes that define varioustreatments that can be administered to patients. In one embodiment, thediagnosis codes and the treatment codes can be selected from the codesand code modifiers of a volume entitled Physician's Current ProceduralTerminology (CPT), which is maintained and updated annually by theAmerican Medical Association.

As shown in FIG. 3, claims form 12B can also include other fields, suchas fields 56, that are to be completed by the medical technician beforethe insurance claim is submitted. In this example, fields 56 are adaptedto receive and display information identifying the patient, a referringphysician, and the health care provider who is to receive payment forthe rendered health care services.

When fields 52, 54, and 56 are filled out by the medical technician, themedical technician submits the information included in these fields toserver system 14 from client system 10. Referring again to FIG. 1,server system 14 receives this information and performs a claimverification process, in response thereto, to determine whether theclaim, as submitted, is in condition for advance payment for servicesrendered. Typically, a determination that the claim is in condition foradvance payment is made if the claimed services correspond to healthcare services that are approved for payment by the patient's insuranceplan. For instance, processor 16 can compare the diagnosis code 42 andtreatment code 44 with a compilation of currently accepted medicalprocedures stored in database 20. In one embodiment, a database ofprevailing health care charges, such as the Medical Data Research (MDR)database, or a customized database compiled by an entity operating thepayment system of the invention is used to determine whether thediagnosis codes and treatment codes correspond to health care servicesthat are approved for payment. Upon learning of the invention disclosedherein, those skilled in the art will understand how an MDR database oranother database can be used to determine whether the submitted claimform represents health care services that are approved for payment.

Database 20 can alternatively be one that is compiled or supplemented onan ongoing or repeated basis as the entity that authorizes the insuranceclaims for advance payment processes large numbers of insurance claimsassociated with particular payers or insurance carriers. For example,the processes disclosed in U.S. patent application Ser. No. 09/634,679,filed Aug. 8, 2000, entitled “Determining the Degree of Acceptance ofProposed Medical Treatment,” which is incorporated herein by reference,can be adapted for this purpose.

Server system 10 also determines whether the information provided inclaim form 12B is sufficiently complete to place insurance claim incondition to be paid. For example, if the medical technicianinadvertently fails to include information that identifies the referringphysician, server system can detect this error and notify client system10 of the deficiency so that it can be remedied.

The claim verification process that is performed by server system 14 canbe as complex as desired. In one embodiment, server system 14 analyzesthe information submitted using claim form 12B to determine whetherthere are indicia of fraud or mistake, whether unusually expensivehealth care services are listed in the claim, or whether other anomaliesare present that suggest the claim is not suitable for advance paymentaccording to the present invention.

One technique that is sometimes used by health care providers to collectmore money from insurance plans than is otherwise warranted is thepractice of unbundling medical procedures. “Unbundling” consists ofperforming, for example, multiple medical procedures on a patientthrough a single surgical incision while submitting an insurance claimfor the multiple medical procedures as if they had been performedseparately. Typically, when only one incision is required to performmultiple medical procedures, the payment to the operating physician isless than the payment would be if each of the multiple medicalprocedures had been conducted through separate incisions. Otherfraudulent unbundling techniques for submitting claims on multiplemedical procedures are sometimes used as well. Thus, server system 14can analyze the diagnosis codes and the treatment codes for indicia ofunbundling practices. Furthermore, server system 14 may conduct anyother checks on the submitted claim. For example, the server system 14may cross reference the patient gender with the diagnosis and treatmentcodes. In would be inappropriate, for example, for a hysterectomy to beperformed on a male or a vasectomy to be performed on a female.

If the claim exhibits any of the foregoing features, the claim may bedenied eligibility for advance payment of funds for services rendered.In which case, the health care provider will have to wait until theclaim is processed and adjudicated by a corresponding carrier.Alternatively, the claim may be returned to the health care provider toallow revision of the claim. For example, the server system 14 cantransmit reply information to client system 10 informing the medicaltechnician of a negative result and can indicate the basis for rejectinga claim. Thus the medical technician can be informed that the claim formwas not completely filled out, the treatment code is inconsistent withthe diagnosis code, or any of a number of other possible reasons forrejecting the insurance claim. In response, the medical technician canamend the insurance claim by entering the correct information to thefields of claim form 12B of FIG. 3, if necessary. In other cases, thehealth care provider can be informed of what diagnosis and treatmentcodes are appropriate for the services that were performed and will beapproved for advance payment, according to the patient's insurance plan.

If the medical technician wishes to amend the insurance claim, the newinformation is transmitted from client system 10 to server system 14 forprocessing. Server system 14 then repeats the previously described claimverification process of determining whether the amended insurance claimis in allowable condition for advance payment. The above-describedprocedure can be repeated as many times as desired or necessary tocreate and submit an insurance claim that describes health care servicesthat are approved for payment by the patient's insurance plan, andsubsequently eligible for advance payment prior to the carrier actuallyprocessing the claim. It should be appreciated that even if it isultimately decide that a submitted claim is not eligible for advancepayment, the claim verification process of the present invention, whichcan take just minutes even when resubmissions are required,significantly reduces the time it takes for a claim to be processed and,if necessary, adjudicated by a carrier. This is particularly true whenthe claim verification process identifies clerical errors that can beidentified and corrected almost instantaneously. It should beappreciated that this is an improvement over the prior art for at leastinforming a health care provider of correctable claim errors early on sothat a health care provider does not have to engage in extensiveresearch, telephone conversations or hold time, and mail adjudicationsjust to place a claim in allowable condition to be paid.

Even though the processing and adjudication of insurance claims may beexpedited in some degree by the foregoing description of the presentinvention, some health care providers find that processing of insuranceclaims by corresponding carriers still takes too long for their needs.This is true even when the claims are submitted in allowable conditionfor payment and are paid as expeditiously as possible through thecarrier administrative systems. To remedy this problem, the presentinvention provides a method and system of promptly paying health careproviders for services rendered, even before the corresponding insuranceclaims can be processed by the appropriate carrier. In particular, thepresent invention provides a payment entity 70, as shown in FIG. 1,which advances a credit of funds to the health care provider forrendered services.

3. Payment of Insurance Claims by Advancing Funds

Returning to FIG. 1, once the server system 14 determines that a claimis eligible for advance payment, the server system 14 transmits claimdata to a payment entity 70, which is in communication with the serversystem 14 through the Internet infrastructure 22. It should beappreciated that the payment entity 70 includes at least one servercomputer to perform the functions described herein by using appropriatecomputer-readable media and computer-executable instructions. In oneembodiment, the payment entity 70 uses a processor 16 b topre-adjudicate the submitted claim. In an alternative embodiment, thepayment entity 70 used the processor 16 of the server computer topre-adjudicate the submitted claim. Pre-adjudication involvesdetermining how much money will be advanced for the claimed services.This determination is made by comparing any combination of the patientinformation 28, insurance information 30, treatment information 40, andother information 32 with archived records of insurance paymenthistories, similar claim payment results, adjudication rules, and thelike. Pre-adjudication also may involve determining how the funds, ifapproved, are to be distributed and into which accounts they are to bedistributed.

In one embodiment, the payment entity 70 communicates the resulting dataof the pre-adjudication to server system 14. The resulting data includesfinancial information which the server system 14 subsequently transmitsto client system 10 to inform the health care provider that thesubmitted claim is in condition for advance payment and the amount thatwill be advanced for services rendered. As a matter of example, claimform 12B of FIG. 3 may include in the amount paid field 58 a dollaramount that is to be promptly paid for services rendered. The advancemay be equal to the amount that was previously determined as beinglikely to be paid by the carrier on behalf of the patient. Receivingthis information permits the medical technician to know exactly how muchmoney to request from the patient for services rendered, in the form ofa co-payment.

To illustrate, the medical technician might enter in field 54 atreatment code that represents a physical exam performed by a physician.The medical technician could then enter in field 60 a dollar amount,such as $100, that represents the physician's charges for performing thephysical exam. Field 62 sums all dollar amounts entered in fields 60. Inthis example, if the physical exam was the only treatment rendered tothe patient, field 62 would also display a dollar amount of $100. If,however, the payment entity 70, when pre-adjudicating the submittedclaim, determines that the patient's carrier typically pays only $90 fora physical exam, field 50 displays the dollar amount of $90 that iseligible for advanced payment according to the invention. A balance duefield 64 displays the difference between the total charge field 62 andthe amount paid field 58. Accordingly, the dollar amount displayed infield 64 represents the amount that should be collected from the patientfor services rendered. As used herein, the term “co-payment” is definedto extend to the dollar amount displayed in field 64, representing theamount that is to be collected from the patient beyond the payment thatis approved for payment by the carrier.

In another embodiment, the amount paid field 58 does not represent theamount that will be advanced in the form of an advance payment, butrather, it represents the coverage amount of the patient's insuranceplan. According to this embodiment, the health care provider can accessEOP data, if desired, on the Internet infrastructure by accessing an EOPwebsite that is updated by the payment entity and/or by correspondingfinancial entities.

Although the previous example goes into some detail regarding how thepayment entity 70 and the server system 14 are in communication,suggesting they are discrete entities, it should be appreciated that thepayment entity 70 and the server system 14 can comprise a singleorganization or single server system.

Using the present invention, medical technicians and health careproviders can be informed of the status of submitted insurance claims ina relatively short amount of time that is significantly less thanconventional systems, which may require days, weeks, or more. Indeed,for practical purposes, a response to the submitted insurance claim isreceived almost immediately by the medical technician. It can beunderstood that the limiting factors with respect to the speed ofresponse include the data transmission rate supported by Internetinfrastructure 22 of FIG. 1 and the other communication links betweenthe various components of the system, the processing capabilities ofprocessor 16 and other components of server system 14, and thecomplexity of the submitted claim and the nature of the claim processingtechniques performed by server system 14. Accordingly, although it waspreviously mentioned that paper claims can be submitted and subsequentlyconverted to electronic form, payment generally occurs earlier whencommunication between the client system 10, server system 14, andpayment entity occurs via an electronic medium, such as the Internetinfrastructure 22.

When an electronic medium is used, the response time is short enoughthat a medical technician can conveniently continue viewing the claimform associated with a particular patient at client system 10 whileserver system 14 performs the operations that determine whether thesubmitted claim is in condition to be paid and while the payment entity70 pre-adjudicates the claim to determine what funds if any will be madeavailable for advance payment. Thus, a medical technician canefficiently and consecutively create and submit a series of claims andreceive verification that the claims are in allowable condition foradvance payment. In other words, a medical technician can easily create,submit, and, if necessary, revise and resubmit, a single claim beforeproceeding to the next claim in a series of claims, since the responsetime can be very short. This is in sharp contrast to prior art systemsin which the response time of days, weeks, or longer make it entirelyimpractical for medical technicians to complete the entire claimcreation and adjudication process for one claim before proceeding to thenext claim.

FIG. 1 also shows that the server system 14 is in communication with acarrier 72, which represents any health insurance company, healthmaintenance organization, fee-for-service health care company,employer-sponsored health insurance, etc. The carrier includesappropriate computer-readable media and computer-executable instructionsto perform the functions described herein. In one embodiment, serversystem 14 transmits claim information to the carrier 72 simultaneouslywith the transmission of the claim information to the payment entity 70.If the carrier 72 is not able to receive electronic claim datatransmitted over the Internet infrastructure 22, then the server systemproduces paper claim documents that are mailed to the carrier 72 viaconventional paper mail systems. The carrier 72 processes the insuranceclaim, which may include adjudication. However, because most of theclaims that are transmitted from the server system are prescreened bythe claim the verification process, it is unlikely that a claim willrequire extensive adjudication. It should be appreciated that thisimproves the overall efficiency of the carrier 72 claim processing andadjudicating processes. Despite this improvement, however, some healthcare providers would prefer to have more immediate payment for renderedhealth care services. To meet this demand, the payment entity 70transmits a fund distribution request to a financial entity 74, such asa bank, requesting that advanced funds be credited into an account thatare immediately accessible to the health care provider for renderedhealth care services. The financial entity 74 may include computersystems and servers to perform the functions described herein by usingappropriate computer-readable media and computer-executableinstructions.

According to one embodiment, the fund distribution request providesinformation for the financial entity 74 to know exactly how much moneyto advance and how to distribute the funds. The fund distributionrequest may, for example, request that the funds be distributed betweena provider operational account 76 that is accessible to the health careprovider and a provider reserve account 78 that is not accessible to thehealth care provider. The funds distributed to the provider operationalaccount 76 are immediately accessible to the health care provider,whereas the funds in the provider reserve account are not accessible tothe health care provider, but instead are debited for service fees,interest on any unpaid balances, and to pay off any unpaid balances.

The following is one example of how a fund distribution request mayoccur and how it enables a health care provider to receive advancepayment for rendered health care services. As a matter of illustrationonly, a health provider submits a claim for $100. After being subjectedto the claim verification process by the server system 14 and thepre-adjudication process by the payment entity 70, it is determined thatthe $100 claim is eligible for an advance payment of only $90. Withinminutes or hours, the payment entity 70 submits a fund distributionrequest to the financial entity 74 for payment of $90 to be paiddistributed between two accounts, $72 (80% of $90) into the provideroperational account 76 and $18 (20% of $90) into the provider reserveaccount 78. Accordingly, the health care provider is then givenimmediate access to $72 for rendered services, even though the paymentrequest submitted to the carrier may not be paid for weeks or months.

Finally, once a carrier 72 completes the processing of a claim andsubmits payment for the claim, the funds are credited to the providerreserve account 78 to pay for previously identified expenses. Thistransfer of funds can occur either electronically or manually. Any fundsremaining in the reserve account 78 after expenses are paid aretransferred to the provider operational account 76 and are accessible bythe health care provider. EOP data regarding fund distribution requestsand actual account transactions is updated and available through theInternet infrastructure 22. EOP data provides health care providers withimmediate access to information regarding what funds are available andwhat credits and debits have been made to the reserve account. Thisinformation can be updated by the financial entity 74 and/or by thepayment entity 70. Once a carrier 72 processes the claim, it submitsexplanation of benefits (EOB) data to the patient, which can be receivedby mail or accessed electronically of the Internet infrastructure 22.

FIG. 4 illustrates a flow diagram of one embodiment of the presentinvention. As shown, in step 80, communication is established betweenthe client system and the server system as described herein. In step 82,the client system receives and displays the claim form to enable themedical technician to enter the information required to complete theinsurance claim. As previously noted, the client system can retrieve theclaim form from the remote server system or from a local data storagedevice. In step 84, the medical technician enters the patientinformation, insurance information, and treatment information to theserver system.

In step 86, the server system determines whether the patient is abeneficiary of an approved insurance plan. The server system, in step86, may also subject the claim to a claim verification process to verifythat the claim does not contain irregularities and to verify that theclaim is eligible for advance payment. If it is determined that theclaim, as submitted, is not in condition for advance payment or if thepatient is not a beneficiary of an approved insurance plan then theclient is notified. The claim can then be revised and resubmitted untilthe claim is placed in condition for advance payment, if possible.

In step 90, after determining that the claim is approved for advancepayment, the server system notifies the appropriate carrier of theinsurance claim. In response, as shown in step 92, the carrier beginsprocessing the claim. If adjudication is necessary then the carrieradjudicates the claim, as shown in step 94. Finally, after processingthe claim, step 92, and, if necessary, after adjudicating the claim,step 94, the carrier provides payment for the rendered health careservices, step 96. The payment is made to the provider reserve account,step 92, which is debited, step 108, for services and advanced fundsthat were previously provided to the health care provider.

As shown in step 98, the payment entity determines how much money toadvance to the health care provider for services rendered and how thefunds are to be distributed. The server is notified of the resultingdecision, which is subsequently passed on to the client system. At thatpoint, in step 100, the client system determines what co-payment, ifany, is required from the patient.

The payment entity submits a fund distribution request to the financialentity, step 102, instructing the financial entity to advance a creditof funds between a provider reserve account, step 106, and a provideroperational account, step 108. The provider reserve account is credited,step 104, with designated advance funds and with any payments that aremade from carriers for processed claims. The funds in the reserveaccount are not immediately accessible to the health care provider, butinstead are debited, step 108, to pay for any service fees, interest,and to pay down any unpaid balance. Any remaining balance in theprovider reserve account is credited to the provider operationalaccount, step 110. The funds in the provider operational account areimmediately available to the health care provider.

The systems and methods disclosed herein can be practiced in combinationwith the systems disclosed in U.S. Pat. No. 6,341,265, issued Jan. 22,2002, which is incorporated herein by reference. For example, the claimpreparation and editing systems of the foregoing patent application canbe employed to determine whether health services are approved forpayment prior to performing health care services. Furthermore, themethods of the present invention can be adapted according to the methodsdisclosed in the foregoing patent application to determine whetherhealth services are eligible for advance payment prior to performingsuch services.

The present invention may be embodied in other specific forms withoutdeparting from its spirit or essential characteristics. The describedembodiments are to be considered in all respects only as illustrativeand not restrictive. The scope of the invention is, therefore, indicatedby the appended claims rather than by the foregoing description. Allchanges which come within the meaning and range of equivalency of theclaims are to be embraced within their scope.

1. In a financial entity system that is capable of communicating with apayment entity that is in communication with a server system thatreceives insurance claims from a health care provider, a method ofadvancing a carrier's portion of payment for health care servicesrendered by the health care provider prior to the carrier making paymenton the insurance claim for the rendered health care services, the methodcomprising: at the financial entity system including computer systemsand/or servers comprising one or more processors and one or more memorystorage devices, configured for receiving from the payment entity asingle fund distribution request via an electronic medium, wherein thepayment entity has pre-adjudicated one or more insurance claims todetermine how much money of the carrier's expected payment is eligibleto be advanced in an advanced payment for rendered health care services,the single fund distribution request specifying how that advancedpayment should be distributed between an operational account and areserve account both located at the financial entity system, wherein thepayment entity pre-adjudicates the one or more insurance claims prior tothe carrier adjudicating the one or more insurance claims, and whereinthe advanced payment is advanced by the financial entity system andcorresponds to the carrier's expected payment as distinct from thepatient's expected payment; crediting a first portion of the advancepayment to the operational account according to the single funddistribution request, such that a data structure representing theoperational account is updated to indicate that the first portion of theadvance payment has been advanced, wherein the first portion of theadvanced payment corresponds to a portion of the carrier's expectedpayment and wherein the first portion of the advanced payment isimmediately accessible to the health care provider; crediting a secondportion of the advanced payment to the reserve account according to thesingle fund distribution request, such that a data structurerepresenting the reserve account is updated to indicate that the secondportion of the advanced payment has been advanced, wherein the secondportion of the advanced payment corresponds to another portion of thecarrier's expected payment and wherein the second portion of theadvanced payment is not immediately accessible to the health careprovider; and after the carrier processes the insurance claim,subsequently receiving payment for the insurance claim from the carrier.2. A method as defined in claim 1, wherein money in the reserve accountis debited to pay for interest on unpaid balances, to pay off unpaidbalances, and to pay for service fees associated with the advancedpayment.
 3. A method as defined in claim 1, further comprising creditingthe reserve account with the payment received from the carrier.
 4. Amethod as defined in claim 1, wherein receiving payment from the carrierincludes receiving from the carrier an electronic fund transfer to payfor the insurance claim.
 5. A method as defined in claim 1, whereinreceiving payment from the carrier includes receiving from the carrier acheck to pay for the insurance claim.
 6. A method as defined in claim 1,wherein the carrier makes payment for the insurance claim after firstprocessing the insurance claim, and wherein the carrier first processesthe insurance claim upon receiving insurance claim information from theserver system that is generated after the health care provider submitsan insurance claim to the server system.
 7. In a financial entity systemthat is capable of communicating with a payment entity that is incommunication with a server system that receives insurance claims from ahealth care provider, a method of advancing a carrier's portion ofpayment for health care services rendered by the health care providerprior to the carrier making payment on the insurance claim for therendered health care services, the method comprising: at the financialentity system including computer system and/or servers comprising one ormore processors and one or more memory storage devices, configured forreceiving from the payment entity a single fund distribution request viaan electronic medium, wherein the payment entity has pre-adjudicated oneor more insurance claims to determine how much money of the carrier'sexpected payment is eligible to be advanced in an advanced payment forrendered health care services, the single fund distribution requestspecifying how that advanced payment should be distributed between anoperational account and a reserve account both located at the financialentity system, wherein the payment entity pre-adjudicates the one ormore insurance claims prior to the carrier adjudicating the one or moreinsurance claims, and wherein the advanced payment is advanced by thefinancial entity system and corresponds to the carrier's expectedpayment as distinct from the patient's expected payment; crediting afirst portion of the advanced payment to the operational accountaccording to the single fund distribution request, such that a datastructure representing the operational account is updated to indicatethat the first portion of the advanced payment has been advanced,wherein the first portion of the advanced payment corresponds to aportion of the carrier's expected payment and wherein the first portionof the advanced payment is immediately accessible to the health careprovider; crediting a second portion of the advanced payment to thereserve account according to the single fund distribution request, suchthat a data structure representing the reserve account is updated toindicate that the second portion of the advanced payment has beenadvanced, wherein the second portion of the advanced payment correspondsto another portion of the carrier's expected payment and wherein thesecond portion of the advanced payment is not immediately accessible tothe health care provider; debiting at least part of the second portionof the advanced payment in the reserve account at least for servicefees; and crediting a remaining part of the second portion of theadvanced payment in the reserve account to the operational account afterthe claim is adjudicated by the carrier.